A neuropsychologic profile of homosexuasl and heterosexuals
Varieties of male-sexual-identity development in clinical practice a neuropsychoanalytic model
1. HYPOTHESIS AND THEORY ARTICLE
published: 22 December 2014
doi: 10.3389/fpsyg.2014.01512
Varieties of male-sexual-identity development in clinical
practice: a neuropsychoanalytic model
Frans Stortelder1,2
*
1
Department of Child and Adolescent Psychiatry, GGZinGeest, Amsterdam, Netherlands
2
Supervising Analyst, Dutch Psychoanalytic Training Institute, Amsterdam, Netherlands
Edited by:
Thierry Simonelli, Université
Européenne de Bretagne, France
Reviewed by:
Simon Boag, Macquarie University,
Australia
Gabriele Roberto Cassullo, Università
degli Studi di Torino, Italy
*Correspondence:
Frans Stortelder, Supervising Analyst,
Dutch Psychoanalytic Training
Institute, Schubertstraat 54,
1077GW Amsterdam, Netherlands
e-mail: f.stortelder@planet.nl
Variations of sexual identity development are present in all cultures, as well as in many
animal species. Freud – founding father of psychoanalysis – believed that all men have an
inherited, bisexual disposition, and that many varieties of love and desire are experienced as
alternative pathways to intimacy. In the neuropsychoanalytic model, psychic development
starts with the constitutional self.The constitutional self is comprised of the neurobiological
factors which contribute to sexual identity development. These neurobiological factors
are focused on biphasic sexual organization in the prenatal phase, based on variations in
genes, sex hormones, and brain circuits. This psychosocial construction of sexual identity
is determined through contingent mirroring by the parents and peers of the constitutional
self. The development of the self—or personal identity—is linked with the development
of sexual identity, gender-role identity, and procreative identity. Incongruent mirroring of
the constitutional self causes alienation in the development of the self. Such alienation
can be treated within the psychoanalytic relationship.This article presents a contemporary,
neuropsychoanalytic, developmental theory of male-sexual identity relating to varieties in
male-sexual-identity development, with implications for psychoanalytic treatment, and is
illustrated with three vignettes from clinical practice.
Keywords: neuropsychoanalysis, male homosexuality, masculine identity, procreative identity, alienated self,
internalized homophobia, psychoanalytic relationship
INTRODUCTION
Varieties of sexual identity development are present in all cul-
tures and in many animal species. Sexual fantasy, behavior, and
identity become differentiated during the development of sexual
orientation. Freud himself – founding father of psychoanalysis –
believed that all men have inherited-bisexual dispositions, and
that many varieties of love and desire are experienced as alter-
native pathways to intimacy (Cohler and Galatzer-Levy, 2000).
Sexual fantasy is a core feature of both homosexuality and het-
erosexuality (Friedman and Downey, 2008). It was in the early
20th century that the concept of homosexual identity developed,
integrating homosexual fantasy with homosexual behavior and
identity (Cohler and Galatzer-Levy,2000). Only recently, however,
did homosexuality become an acceptable, socio-cultural category
of sexual identity within modern, Western culture.
How does sexual identity develop? Psychic development begins
with the constitutional self. The constitutional self comprises the
neurobiological factors contributing to sexual identity develop-
ment. These neurobiological factors are focused on biphasic-
sexual organization in the prenatal phase, based on variations
in genes, sex hormones, and brain circuits. This psychosocial
construction of sexual identity is determined through contin-
gent mirroring by the parents and peers of the constitutional
self. The development of the self—or personal identity—is linked
with the development of sexual identity, gender-role identity, and
procreative identity. Incongruent mirroring of the constitutional
self causes alienation during self development. Such alienation
can be treated within the psychotherapeutic relationship by the
psychoanalyst.
This article presents a contemporary neuropsychoanalytic-
developmental theory of male-sexual identity relating to varieties
of male-sexual-identity development, while offering implications
for psychoanalytic treatment, and is illustrated by three vignettes
from clinical practice.
THE NEUROPSYCHOANALYTIC MODEL
Neuropsychoanalysis links models for psychoanalytic and neu-
robiological development through interdisciplinary perspective.
Neuropsychoanalysis proposes that brain development and psy-
chic development are interrelated. Changes in brain structure and
function go together according to the structure-function princi-
ple (Schore, 1997). In the 20th century, psychoanalysis developed
as a clinical science with a changing neuropsychoanalytic per-
spective. Unifying mind-body concepts evolved, from Freud’s
“drive-concept”—which bridged biological and psychic drives—
to the “energy-concept” of Ego Psychology—which connected
psychic-energy processes with neurophysiologic-energy processes
inthebrain. Contemporarypsychoanalysisisneuropsychoanalytic
in its use of a unifying “representation concept.” The repre-
sentation concept connects mental representations with neural
representations, e.g., visual or motor, in the brain (Stortelder and
Ploegmakers-Burg, 2010).
Theneuropsychoanalyticmodeladherestothebio-psychosocial
view that brain structure and function are programmed by
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2. Stortelder A neuropsychoanalytic model
interpersonal experiences, resulting in the development of the
psyche. Psychic development, which starts with the constitu-
tional self, comprises inborn personality characteristics including
sexual identity, constitutional developmental capacities, as well
as genetic-risk factors for the development of psychopathology
(Gergely,2007). The self must take an active role, as a mental agent
interacting with its environment, to socio-culturally construct its
own personal and sexual identity.
The neuropsychoanalytic model also adheres to the ontogenetic
principle in the evolution of living systems. Early development
creates the foundation for the functioning of an organism for
the rest of its life. New organization recapitulates and develops
out of previous stages. Likewise, according to the ontogenetic
principle of psychoanalysis, the development and organization
of basic, psychic functions occur in the first 5 years of life, while
a re-organization takes place during adolescence. Neurobiologi-
cal research confirms that the basic growth and maturation of the
brain occurs during the first 5 years of life, while a substantial reor-
ganization in brain development transpires during adolescence
(Stortelder and Ploegmakers-Burg, 2010).
Our article, “adolescence and the reorganization of infant
development: a neuropsychoanalytic model” (Ibid), presented a
neuropsychoanalytic-developmental theory which distinguished
between psychosexual, emotional, and cognitive developmen-
tal domains, along with the domains for the development of
self-agency and self-concept. Here is a brief review of the neu-
ropsychoanalytic model for the development of self-concept or
identity—as specified by sexual identity—in which early neurobi-
ological development must be considered.
NEUROBIOLOGICAL MODEL OF SEXUAL IDENTITY
DEVELOPMENT
The development of sexual identity starts with the constitu-
tional self. In the current view of sexual identity development,
inborn-neurobiological factors play an important role. The neu-
robiological model of sexual identity development consists of
gene-expression, neurochemical and brain development.
DEVELOPMENT OF GENE-EXPRESSION
From behavioral genetic studies, it is known that homosexual-
ity runs in families. Studies of twins show that among pairs
of male-monozygotic twins, 52% are both homosexual; among
pairs of male-dizygotic twins, 22% are both homosexual (Bailey
and Pillard, 1991). In a study of adult sons of gay fathers 9%
showed exclusive homosexual orientation (Bailey et al., 1995). In
a longitudinal study of 17-year-old adolescents—an age where
sexual identity is not yet fully crystallized—who were reared in
lesbian families, 0% of the girls and 5.4% of the boys identified
as homosexual, while 18% of the girls rated themselves on the
bisexual spectrum (Gartrell et al., 2011). In an average population,
approximately 3% of females and 4% of males express exclu-
sively homosexual desires. The percentage of homosexuality may
increase through genetic transmission from parent to child. How-
ever, the children of homosexual parents grow up predominantly
identifying as heterosexual (Tasker and Patterson, 2007).
Along with other personality traits, the heredity of human-
sexual identity is thought to be polygenetic, determined by
multiple genes. Separately these genes have a low chance for
expression. Combined in one carrier, they may surpass a thresh-
old leading to homosexuality. The search for homosexual genes
resulted in the finding of the Xq28 gene, transmitted across the
maternal side of the family (Hamer and Copeland, 1994).
NEUROCHEMICAL DEVELOPMENT
Neurochemistry includes the study of neurohormones and neuro-
transmitters. Most research, concerning neurochemical influence
on the development of sexual identity, focuses on the Prenatal
Androgen Theory. The theory suggests that genetic variation leads
to variation in the influence of prenatal androgens. Such variation
determines sexual differences within the brain in terms of gender
identity (maleness and femaleness), gender-role behavior (mas-
culinity and femininity), and sexual identity (erotic fantasy and
desire for intimate relationship).
The chromosomes XX cause the embryogenesis of female gen-
itals through the Mullerian duct, and the chromosomes XY of
male genitals through the Wolffian duct. The Y chromosome acti-
vates a gene, the testis determining factor, which begins developing
the testes. The testes start releasing the male sex-hormone testos-
terone, masculinizing the Wolffian system, so that male genitals
may develop. In a female fetus lacking theY chromosome,the Mul-
lerian Duct develops into female genitalia. The prenatal androgens
determine the development of maleness. If there are no prenatal
androgens, the fetus will be female.
Prenatal sexual organization has a biphasic course, begin-
ning with the sexual differentiation of the genitals occurring
during the first 2 months of life. Sexual organization of the
brain occurs during the second half of pregnancy. Its activa-
tion becomes overt, in the postnatal phase throughout the first
5 years of life, as well as during puberty. The Prenatal Andro-
gen Theory postulates that male homosexuality is due to variation
in levels or function of prenatal androgens, during the prenatal-
masculinizing-brain development in the second half of pregnancy.
Variation in androgen levels or function may only be present
prenatally. Among adults, there is no difference between the
sex-hormone levels of homosexuals and heterosexuals (Bao and
Swaab, 2010).
BRAIN DEVELOPMENT
Within the brain, psychosexual function is primarily organized
by the hypothalamus, which regulates other vital bodily func-
tions such as hunger, body temperature, circadian cycle, and
stress. Brain research, relating to genetic variation and variation
in the function of prenatal sex-hormones, focuses on structural
variations of the hypothalamus. These hypothalamic structures
organize sexual motivation and orientation, especially the sexu-
ally dimorphic nucleus of the pre-optic area. Swaab and Hofman
(1990) found that the interstitial nucleus of anterior hypotha-
lamus 1 (INAH-1) in the hypothalamus of homosexual men is
intermediate in size between the hypothalami of heterosexual men
and heterosexual women. LeVay (1991) discovered that the size of
INAH-3 in homosexual men is smaller than in heterosexual men,
while larger than in heterosexual women.
Thus, the constitutional self of sexual identity development
has a multifactorial determination. The constitutional factors
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3. Stortelder A neuropsychoanalytic model
attributed to sexual identity development are not determined by
a sole gene, hormone, or brain localization, but dependent on
multiple genetic, neurochemical, and neural networks. Further
research on the complex biodiversity of human-sexual-identity
development is needed.
PSYCHOANALYTIC MODEL OF SEXUAL IDENTITY
DEVELOPMENT
In the psychoanalytic model, the development of sexual identity
is the result of the interaction between the constitutional self and
psycho-social experiences. Our article “adolescence and the reor-
ganization of infant development: a neuropsychoanalytic model”
presented a psychoanalytic model of psychic development, dis-
cussing the psychic dimensions of psychosexual development,
relating to emotional and cognitive development, and devel-
opment of the self. The development of the self is primarily
determined by the formation of the self-concept. The self-concept
comprises the self as an object (“Me-self”), and must be distin-
guished from self-agency or the self as a subject (“I-self”). What
follows is a review of the psychic development of the self-concept,
or personal identity, specified by linked domains of sexual identity,
gender identity, and procreative identity.
THE DEVELOPMENT OF PERSONAL IDENTITY
The development of a conscious sense of self starts by age
one-and-a-half when the toddler recognizes itself in a mirror. Rep-
resentations of the self-concept are concrete during childhood;
in adolescence they become more abstract and more dependent
on romantic attractiveness, as well as status at school and work
(Harter, 2012). The development of self-representations is deter-
mined mostly during early childhood in the mirroring interaction
with parents. During latency and adolescence, it is also determined
by the mutual affirmative interactive process with peers and school
(Ibid).
Fonagy et al. (2002) describe a psychoanalytic model of the
mirroring process through the mechanism of affect mirroring.
Affect mirroring consists of four aspects: the focal attention to
and recognition of affect; the interpretation and representation
of affect; the modulation of affect; the expression of an emo-
tional response or action. In Fonagy’s model, the infant finds its
primary emotional state represented by the markedly mirrored
affect representation of the caregiver, decoupled from the realistic,
affect representation of the caregiver, as well as anchored within
itself as a secondary-affect representation. The infant is looking
for a high-but-imperfect, contingent representation of its own
affect in the mirroring caregiver, using a contingency detection
module.
The interpretation of the infant’s affect by the caregiver forms
an essential part of the process of affect mirroring. For exam-
ple, if an infant cries from hunger, the contingent-mirroring
caregiver says: “you are crying (affect recognition). You are hun-
gry (affect interpretation/representation). Just be quiet (affect
modulation). You get a bottle (emotional response/action).” A
congruent, secondary-affect representation develops in the infant,
along with a contingent, self-to-other, causal-emotional scheme.
In the mirroring process, the infant has an active role as a mental
agent through contingency detection. This means that his crying
stops when he gets the expected response. However, the non-
contingent, mirroring caregiver says:“you are crying.You are tired.
Just be quiet. You are going to be put in bed to sleep.” The infant
gets an incongruent mirroring of its affect and a non-contingent
response. The incorrect interpretation of its caregiver leads to the
development of a non-authentic or alienated, secondary affect-
representation with a distorted, other-to-self causal-emotional
scheme (Gergely).
The following model (Figure 1). accounts for the mirroring
of mental states leading to the development of mental represen-
tations, and of self-states leading to self-representations. It shows
the development of an autobiographical self. This occurs through
the parents’ congruent mirroring of the authentic self of the child.
Incongruent mirroring of the authentic constitutional self leads
to the development of an alienated self. In the neurobiology of
the mirroring process, mirror neurons play a role in the implicit,
simultaneous resonance within the self, reflecting the caregiver’s
intentions (Gallese, 2009).
Psychoanalytic treatment aims to change the non-authentic or
alienated self. In the alienated self, there is an unconscious conflict
betweenalienatedself-representationsandthedefended,authentic
self. During psychoanalytic treatment, these unconscious, alien-
ated self-representations are brought into the transference by
the patient, then marked and made conscious in the mirroring
counter-transference by the psychoanalyst, and is decoupled from
the psychoanalyst’s realistic self-representations (Figure 2). Such
alienated self-representations are interpreted so they can be con-
trolled and rejected. During this process, counter-transference
consists of two aspects: representations originating from the
transference of the patient, and realistic representations origi-
nating from the psychoanalyst. If the psychoanalyst mirrors a
realistic self-representation, the mirroring is non-contingent and
counter-transference becomes pathological.
FIGURE 1 |The Affect Mirroring model: in the child, secondary
self-representations (“S”) of the constitutional self (“C”) are formed
through the contingent mirroring self (“M”) of the parent, decoupled
from his realistic self (“R”). In the case of incongruent mirroring by a
realistic self-representation (“R”) of the parent, alienated secondary
self-representations (“AS”) are formed in the child (Stortelder and
Ploegmakers-Burg, 2010).
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4. Stortelder A neuropsychoanalytic model
FIGURE 2 |The treatment of the Alienated Self: first, unconscious
alienated self-representations (“AS”) of the patient are made
conscious, in the transference-countertransference process, by the
marked mirroring of the psychoanalyst (“M”), decoupled of the
realistic self (“R”), and interpreted, so that they can be controlled and
rejected by the patient. New, contingent secondary self-representations,
of the previously defended authentic self of the patient, are developed
through the therapeutic mirroring of the psychoanalyst (Ibid).
In the phase of ‘working through,’ the psychoanalyst serves as
a developmental object, stimulating the development of new, con-
tingent, secondary self-representations of the previously defended,
authenticself bythepatient. Thepatienthasanactiverole,through
contingency detection, in the psychotherapeutic process. The
patient reacts positively, feeling recognized and affirmed by the
congruent mirroring of the psychoanalyst.
The development of an adult-personal identity is a core task
during adolescence. Adult identity denotes a sense of consistency
and continuity of the self, as well as a sense of personal norms
and ideals. Erikson (1968) regards adolescence as an experimental
period (“moratorium”), for discovering and building the vari-
ous aspects of the authentic adult identity. Identity formation
occurs, particularly in middle adolescence, by contact with like-
minded peers, who validate and admire each other while sharing
joint activities and ideas. During this mutual, mirroring process,
mirror neurons play an essential role in the formation of indi-
vidual identity—in its relation to social identity—through social
identification (Gallese).
Music and clothing styles serve as identity markers and can
be regarded, during treatment, as a window into an adolescent’s
internal world. There are innumerable social groups, including
skaters, rebels, punks, emos, and goths. Online role-playing fan-
tasy games, such as World of Warcraft or Still Life can provide the
adolescent with a virtual-transitional space to play with new iden-
tities. In identity formation, it is important for the adolescent to
have a private space, to pose as a temporary outsider free from the
rules and restrictions of the parental home. The adolescent needs
to search for his own authentic identity based on his own expe-
rience, and by mirroring his peers. Adolescents should be able to
fall back occasionally on the secure relationships of the parental
home, while retaining the opportunity to experiment in the future,
adult world. For homosexual adolescents, the LGTB community
can offer such a private space (Stortelder and Ploegmakers-Burg,
2010).
DEVELOPMENT OF SEXUAL IDENTITY
Friedman and Downey (2008) present an extensive historical
overviewof psychoanalytictheoriesof sexualidentity. Indeed,they
propose a contemporary psychoanalytic model of psychosexuality.
In their design, psychosexual development starts in the prenatal
stage under the influence of sex chromosomes. The development
of the hypothalamic-pituitary-gonadal axis (HPG–axis) and the
production of the sex-steroid hormones begin this process. These
determine the embryogenesis of the reproductive system and the
prenatal programming of the sexual brain, with the organization
of psychosexual development during the first 5 years of life, as well
as the activation of the HPG–axis at the onset of puberty.
After about 6 months, infants start to touch their genitals and
experienceeroticarousal(RoipheandGalenson,1972). Childhood
masturbationisespeciallyfrequentbetweenagestwothroughfour.
Starting around age four, erotic feelings and fantasies develop
within a romantic, oedipal scenario. The inner narratives of these
intrafamilial relationships become unconscious mental scripts
for later, extra-familial relationships (Friedman and Downey,
2008).
Isay (1989) points out one way in which varieties in sexual
identity development may be encountered in clinical practice. The
pre-homosexual boy may develop unconscious romantic feelings
and fantasies involving same-gender peers by kindergarten age,
and may also have feelings directed toward his father. The pre-
homosexual boy distances himself from his same-gender peers
and father in order to avoid recognition of his romantic attach-
ment. The boy’s self-perception of these silent, same-gender, erotic
emotions may account for feelings of self-isolation and alienation.
In return, the father may become detached and hostile toward his
son. The father may unconsciously sense the son is different from
other boys, as well as the son’s need for closeness and romantic
attachment.
The father’s withdrawal is experienced as rejection by his son,
along with a sense of masculine inadequacy. The father may
present himself as a role model, and try to enhance heterosex-
ual and masculine development in the son. Why? He believes that
doing so will improve his son’s popularity with peers. Unconscious
conflict develops between the alienated, self-representations and
the defended, authentic self of the son, due to incongruent mirror-
ing by the father. Such unconscious conflict leads both to feelings
of alienation and inadequacy in the son’s personal and masculine
identity, and to internalized homophobia (Drescher, 1998).
During clinical practice, the psychoanalyst may encounter an
adult patient with depressive symptoms and personality problems.
Here, as shown in the first vignette, an unconscious conflict exists
between the alienated self and the defended authentic self—caused
by incongruent mirroring. This unconscious conflict leads to feel-
ings of internalized homophobia, as well as feelings of inadequacy
in masculine and personal identity.
Vignette 1
Robert is a 28-year-old homosexual male who came into psychoan-
alytic treatment for depressive symptoms and narcissistic personality
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5. Stortelder A neuropsychoanalytic model
features. He was the youngest of three children. As a child of
kindergarten-age, Robert already regarded himself as being differ-
ent from other boys. He experienced silent same-gender wishes, and
felt unable to live up to his father’s expectations. His father strove
to strengthen his son’s masculinity and popularity with other boys.
Robert enjoyed sports, especially basketball. He became a player with
the local, premier team. Yet his father remained dissatisfied with his
son’s achievements in sports, and pushed him toward a better way –
the father’s own more competitive, macho way—of playing.
During puberty, Robert struggled to come out openly. His father
felt personally hurt and attacked in his paternal role, and responded
with a rejecting attitude. Eventually Robert did well academically,
and grew up to become a psychologist. Still, Robert developed per-
sonality problems, along with feelings of depersonalization, and
depressive symptoms. Through long-term treatment, Robert grad-
ually became conscious of the origins of his internal homophobia, as
well as of his alienated, weak, personal and masculine identity. He
became able to perceive how he had undergone incongruent mirror-
ing by his father and peers. The result? Robert was able to distance
himself. Thankstoaffirmativetreatmentbyhispsychoanalyst, Robert
developed a more authentic, confident self.
In this vignette the authentic homosexual, masculine and personal
self was defended in childhood by devaluation and rejection as central
interpersonal affective pattern (Lemma et al., 2011). In the psycho-
analytic relationship, first the defended authentic self was made
conscious and then new congruent secondary self-representations
were developed by acknowledgement and affirmation in changing
the core interpersonal affective scheme.
During puberty, the level of sex-steroid hormones rises
strongly, leading to the emergence of adult sexual desires.
The awareness of erotic sexuality and of the object of sexual
desire starts in late latency. Such awareness develops within an
oedipal-representational framework. By early adolescence, the
development of the ownership of the sexual body—with adult
masturbation and sexual fantasies—is intense,but mostly secretive
and concealed. Sexual-fantasy programming consolidates with the
formation of adult-erotic fantasies or love-maps. The erotic fan-
tasies of adult heterosexual and homosexual males end up being
both similar and varied (Friedman and Downey, 2008).
During adolescence, the emergence of conscious, homosex-
ual fantasy fosters the development of adult homosexual identity.
About 20% of homosexual youth report personal distress while
coming out. Peer harassment is experienced by 50% of homosex-
ual youth, especially in early and mid-adolescence. Homosexual
men are confronted by the risk of coming-out distress and by the
challenge of creating their own lives within the context of a non-
normative, developmental pathway. Yet such challenges may also
lead to new opportunities.
DEVELOPMENT OF GENDER IDENTITY
The development of gender identity starts at birth with gen-
der assignment. By age one-and-a-half, core-gender identity is
formed: the consciousness of being a boy or girl. Curiosity
about gender difference is visible during childhood, sexual-
explorative play. For a boy, the psychosocial construction of a
solid, masculine identity occurs in childhood during the oedipal
situation by affirmative interaction with his parents, and again
in adolescence specifically during affirmative interaction with his
peers (Stortelder and Ploegmakers-Burg, 2010).
Gender-role behavior in boys frequently involves rough and
tumble play (RTP). RTP involves acts of dominance, aggression,
and competition. Gender-role behavior in girls typically involves
maternal-doll play and princess-doll adornment with jewelry,
make-up, and feminine clothes. There is asymmetry between the
sexesinthetoleranceof gendernon-conformitybypeers. Tomboys
are likely to be accepted by both boys and girls, while gender
non-conformant boys, e.g., “sissies,” are depreciated and bullied
(Friedman and Downey, 2008).
Throughout childhood, girls are more drawn to the company
of single female best-friends. During play, girls tend to be more
verbal, empathic, and relational. Female, juvenile-peer groups
are smaller, more flexible, and more organized around mutual
empathic communication in durable relationships (Ibid).
During early adolescence, gender segregation in peer groups
is an almost universal phenomenon. Male peer groups tend to
be hierarchically organized and larger than female groups, con-
sisting of up to 5–8 individuals. In play, juvenile boys tend
to be dominant and competitive, devaluing behavior deemed
weak or non-masculine. The gender-role insecurity boys expe-
rience motivates them to become defensively homophobic. In
juvenile-male groups, terms such as “homosexual,” “queer,” and
“faggot” connote behavior considered weak or feminine—rather
than behavior related to sexual identity per se (Ibid). Boys
accepted by their peers experience increased masculine secu-
rity. Boys rejected by their peers experience extremely low status
within their group, and undergo a sense of shameful, masculine
inadequacy.
During clinical practice, the psychoanalyst may encounter an
adult patient with homosexual wishes and a severely vulnerable,
masculine identity. Here, an unconscious conflict exists between
the alienated self—comprised of homosexual wishes serving as a
defense against a vulnerable, masculine and procreative identity—
within a heterosexual patient. This second vignette shows how
such unconscious conflict leads to depressive symptoms and
personality problems.
Vignette 2
Andy, a 32-year-old lawyer, has been in a relationship with a 30-
year-old female nurse for a year. Andy is referred for psychoanalytic
treatment due to personality problems and depressive symptoms.
He reports having problems in sexual identity development, along
with preoccupation and doubts about being homosexual. During his
assessment, Andy discusses his strong preoccupation with develop-
ing a homosexual identity. He expresses doubts about continuing
the relationship with his girlfriend, which he discusses openly with
her. Andy goes out looking for romantic relationships with homosex-
ual friends. Though he had relationships with a few women before
his girlfriend, he had often felt inadequate. His previous girlfriend,
before the nurse, had dumped him in a painful way. Still, Andy’s
erotic fantasies are not same-gender oriented.
During psychoanalytic treatment, Andy seems to have developed a
strong sense of masculine insecurity and inadequacy, as well as doubts
about the development of his procreative identity. He worries whether
he can meet the responsibilities of marrying his girlfriend: founding a
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6. Stortelder A neuropsychoanalytic model
family, having children, becoming a father. Andy reports that he had
been regularly beaten up by his stepfather since early childhood. This
man came into his life when he was 1 year old, his biological father
being absent. Andy, the youngest of three brothers, was a small and
weak child. He was bullied by peers. He had also been humiliated
by his two bigger and stronger brothers. Upon reaching puberty, his
brothers had forced him to grant them sexual favors. Recalling his
youth, Andy says his only special, affirmative remembrance is of a
high-school teacher who positively mentored him and served as a
father substitute.
During psychoanalytic treatment, Andy demonstrates a strong
“father hunger.” Through the psychoanalytic relationship, Andy
becomes conscious of how his alienated and weak masculinity is
connected to those devaluing experiences with his stepfather, peers,
and older brothers. Andy gradually distances himself from feelings of
devaluation. He looks to unconsciously repair his vulnerable, mas-
culine self through the affirmation and admiration of homosexual
friends. Thanks to the father-transference with his psychoanalyst,
who serves as a new, developmental object, Andy is able to create a
solid, masculine, heterosexual identity. Eventually Andy marries his
girlfriend and fathers two children.
In this vignette the authentic heterosexual, masculine, personal
and procreative identity was defended in childhood abuse and
humiliation as central interpersonal affective pattern (Lemma et al.,
2011). In the psychoanalytic relationship, first the defended authentic
self was made conscious and then new congruent secondary self-
representations were developed by fathering and strengthening in
changing the core interpersonal affective scheme.
Studies report that many homosexual men and women expe-
rienced gender non-conformity during childhood. Cohler and
Galatzer-Levy (2000) emphasize how sexual identity (erotic fan-
tasy) and gender-role behavior (masculinity and femininity) are
not necessarily related. Yet the anatomical sites that regulate sexual
behavioraredistinctfromtheanatomicsitesthatinfluencegender-
role behavior (Friedman and Downey,2008). Strong, cross-gender
interest during childhood is linked with homosexuality to a certain
degree, yet it cannot predict homosexual identity. Many gender-
non-conforming children become heterosexual. According to a
clinical study of 77 children with gender identity disorder (GID)
during adolescence, 20% of the GID children persisted and applied
for sex-reassignment, while 80% ceased being gender dysphoric.
Within this desistence group, about half of the boys and all of
the girls with childhood GID developed in an adult, heterosexual
direction (Wallien and Cohen-Kettenis, 2008). Homosexual men
likewise demonstrate great diversity in gender-role behavior from
the hyper-masculine (“leather men”) to hyper-effeminate (“drag
queens”), to displays of average masculine behavior (Cohler and
Galatzer-Levy, 2000).
DEVELOPMENT OF PROCREATIVE IDENTITY
Erikson (1968) describes the central psychological developmen-
tal task of middle adulthood as the progression to generativity
versus stagnation in self-absorption. Generativity involves beliefs
and actions which express concern for the next generation’s wel-
fare. The procreative identity demonstrates how a human being
perceives and expresses consciousness as an individual creating
and caring for offspring. The common way of caring for the
next generation is through biological procreation. Darwin (1859)
introduced the evolutionary theory of biological procreation as
the transmission of genes to the next generation. Darwin (1859)
emphasized the importance of continuity of the species; how con-
tinuous genetic variation and natural selection are the sources and
driving forces of evolution. In the struggle for life, genetic varia-
tion or biodiversity makes humans flexible enough to adapt to an
ever-changing environment.
From an evolutionary perspective, homosexuality has been
continually present in many cultures and animal species.
Bagemill’s (1999) research shows that homosexual behavior occurs
in 300 vertebrate species. According to numerous, cross-cultural
studies, homosexual behavior appears to be present in many cul-
tures,such as the tribe of the Sambia in New Guinea,and in ancient
cultures of Greece, Japan, and China (Aldrich, 2006). But what is
the evolutionary, adaptive benefit of biologically non-reproducing
homosexuals?
Onemajortheorysuggeststhatculturalevolutionoccursalong-
side biological evolution (Dawkins, 1976). Cultural evolution
follows principles similar to biological evolution. Elements of
culture—e.g., ideas, skills, faiths, and science—are copied and
transmitted to the next generation, from brain to brain. Accord-
ing to Dawkins (1976), cultural evolution has gradually influenced
biological evolution. The human brain has grown in size, from 500
to 1500 g, in the service of cultural evolution.
Procreative consciousness is present in children from age five.
In a clinical child-psychiatric assessment,most children spoke pos-
itively about whether they as adults would like to get married and
have children. Research shows that during adolescence this pro-
creative consciousness is equally present in young homosexual and
heterosexual men (Berkowitz, 2007). Some homosexual men and
women shape their generativity by means of biological procre-
ation, others by means of cultural procreation. The masculine,
procreative identity involves becoming a father, and develop-
ing the capacity for paternal, watchful protectiveness (Diamond,
1997).
Today, a significant number of openly homosexual men have
children by committing to a parental alliance with a lesbian cou-
ple, or by surrogacy or adoption. Many family modes of differing,
parental alliances of lesbian mothers and homosexual fathers exist.
Such alliances vary: from co-parenting, to visiting schemes of one-
to-several days a week and alternate weekends. Such constellations
of parenting leave open the possibility that a child may later wish
to explore the genetic contribution of both parents to his constitu-
tional self and to his identity development (Golombok and Tasker,
2010).
Back in the 1970s, researchers studying homosexual parent-
hood questioned whether children growing up in homosexual
families were at special risk for developing psychological prob-
lems and gender disturbance. In these studies, no differences in
psychological development between children of homosexual and
heterosexual parents were found. More recent studies indicate that
lesbian and gay families—being very much pre-planned—report
better-quality partner relationships and better relationships with
children than in the heterosexual population, where unintended
pregnancies occur far more frequently (Goldberg,2010). However,
the psychological outcome for adult children of gay and lesbian
Frontiers in Psychology | Psychoanalysis and Neuropsychoanalysis December 2014 | Volume 5 | Article 1512 | 6
7. Stortelder A neuropsychoanalytic model
parents from a prior generation—specifically an adult who is the
product of a parent’s early, failed, heterosexual union—is poorer
than the psychological outcome for adult children from intact
heterosexual families. Why? They not only had to deal with the
disclosure process of their homosexual parent, but with their par-
ents’marital conflict and divorce, and with their own reorientation
following the family break-up, along with loyalty conflicts and fear
of abandonment (Goldberg).
A new wave of research is examining the dynamics of same-
gender parenting, and how different kinds of homosexual family
experiences have implications for child development (Telinga-
tor and Patterson, 2008). Such studies indicate that homosexual
fathers focus particular attention on normative, gender-role
socialization in their heterosexual sons. Adolescent children of
homosexual parents may experience some degree of embarrass-
ment, however, in regard to public exposure of their parents’sexual
identity.
In clinical practice, the psychoanalyst may encounter an openly
homosexual father with a heterosexual son. The son’s questioning
of his father–son relationship emerges in early adolescence. For
the early-adolescent-heterosexual boy, unconscious conflict may
arise. Such conflict will likely consist of fear of homosexual iden-
tity linked to age-related insecurity in masculine development. A
temporary distancing may then occur between the heterosexual
son and his homosexual father, leading to questions about the
procreative identity of the homosexual father, as shown in this
third vignette.
Vignette 3
John is a 45-year-old business man, who comes for consultation about
questions regarding the relationship with his son and doubts about
his role as a gay father. John has been in a relationship with his male
partner for 20 years, and has been married for 8 years. He and his
partner have a parental alliance with two lesbian mothers. John is the
biological father of a son, Michael who is 13 years old and a daughter,
age 10. Michael and his sister are from the same biological mother
and father. Since birth, the children have lived with the mothers
and visited the fathers 1 day per week and every other weekend. The
mothers live nearby. Michael has developed well psychologically.
In regard to Michael’s psychosexual development, John noticed
that Michael appeared to be developing in a heterosexual direction
since kindergarten age. Michael showed some romantic interest in a
girl in his class at age five, and had reveries about later marrying
his mother. He had a girlfriend when he was 10. The father–son
relationship developed positively, until Michael reached early ado-
lescence, when some distancing in the relationship occurred. This
distancing induced John’s worries about his procreative identity as a
gay father. In psychoanalytic treatment, it appeared that Michael was
experiencing an emergent, age-related, homophobic attitude within
his male peer group. Because of peer-pressure, Michael developed
a normal, temporary, homophobic attitude and felt unease—in his
sexual identity and masculinity formation—about the relationship
withhishomosexualfather. Inpsychoanalytictreatment, Johnstarted
to understand the homophobic reactions of his son, as well as his
own feelings of hurt and rejection, and learned how to handle them.
The father–son relationship became normalized again after Michael’s
early adolescence.
In this vignette first the authentic emerging heterosexual and mas-
culine identity in the son is temporary defended by a homophobic
attitude, which decreases with age because of further maturation
and strengthening of the heterosexual and masculine identity. The
authentic homosexual and procreative identity of the father is chal-
lenged and defended because of distancing and rejection. In the
psychoanalytic relationship first the authentic self is made conscious
and then restored by clarification and validation.
CONCLUSION
In clinical psychoanalytic practice, several varieties of sexual
identity development can be encountered as examples of uncon-
scious conflicts between the alienated self-representations and
the defended, authentic self. As shown in the first vignette,
incongruent mirroring leads to feelings of alienation and of inade-
quacy in personal and masculine identity, along with internalized
homophobia, in a homosexual patient. In the second vignette,
homosexual wishes and questions about homosexual identity
arise, as a defense against a vulnerable masculine and procre-
ative identity, in a heterosexual patient. In the third vignette, fear
regarding homosexual identity, linked to age-related insecurity in
masculinity development, arises in early adolescence in a hetero-
sexual boy. In homosexual parenthood, a temporary distancing
emerges in early adolescence between the heterosexual son and
homosexual father, leading to questions about the procreative
identity of the homosexual father.
In the contemporary, neuropsychoanalytic model, the devel-
opment of sexual identity is caused by the interaction of consti-
tutional factors and psycho-social influences in which the cultural
framework is also important. The model of Affect Mirroring pro-
vides a suitable model for the development of the self, as specified
in personal gender-role, sexual and procreative identity. Incongru-
ent mirroring leads to unconscious conflict between the defended,
authentic self and alienated self representations. As demonstrated
in all three vignettes, such unconscious conflicts can be expressed
clinically in feelings of depersonalization, personality problems,
depressive symptoms, and internal homophobia. Varieties of sex-
ual identity development are often linked to difficulties in personal
gender-roleorprocreative-identitydevelopment,alsodescribedby
the vignettes. This psychoanalytic model, presented for the treat-
ment of the non-authentic or alienated self in the psychoanalytic
relationship, may be helpful in clinical practice, as demonstrated
in the vignettes.
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Bailey, J. M., Bobrow, D., Wolfe, M., and Mikach, S. (1995). Sexual orientation
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Bailey, J. M., and Pillard, R. (1991). A genetic study of male sexual orientation. Arch.
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